Systematic Review of Testicular Torsion in the Emergency Department

The Case

10-year-old male presented to the emergency department via EMS for right lower quadrant abdominal pain. He woke up with severe, sudden onset right lower quadrant pain this morning, approximately 1 hour prior to arrival. Endorsed associated nausea with multiple episodes of nonbilious, nonbloody emesis. The patient was accompanied by his mother who stated she called 911 due to the patient’s inability to ambulate due to the pain. The patient stated that every bump in the ambulance made his pain significantly worse. However, he denied fever, chills, cough, dysuria or diarrhea. He had no prior medical history and was up to date on his immunizations. Denied recent sick contacts.

Physical exam demonstrated a soft, nondistended abdomen but had tenderness in the RLQ with guarding, concerning for surgical abdomen. Genitourinary exam deferred.

The emergency physician obtained a CT of patient’s abdomen and pelvis which showed moderate stool burden and a normal appearing appendix. He tolerated a PO challenge and was discharged home with miralax.

The patient returned to ED approximately 7 hours later (approximately 10 ½ hours from initial onset of pain) with worsening abdominal pain and intractable nausea and vomiting. He ambulated to the exam room from triage clenching his right lower quadrant. Repeat exam revealed a soft abdomen but tenderness in his right groin. A testicular exam showed horizontal lie of the right testicle with significant tenderness to palpation but an intact cremasteric reflex.

Urology was consulted and a stat scrotral ultrasound was obtained. Ultrasound confirmed testicular torsion (patient’s ultrasound images shown below. He was taken emergently to the OR and was found to have a salvageable but cyanotic testicle. Bilateral orchidopexy was performed. Upon discharge, close outpatient urology follow up was arranged.

Clinical Questions

Torsion of spermatic cord [8]

1. What is the most common presentation of testicular torsion?

Patients classically present with an abrupt onset of severe testicular or scrotal pain, usually of less than 12 hours' duration; however, inguinal or lower abdominal pain may be the presenting complaint. Nearly 90 percent of patients may have associated nausea and vomiting. The pain can be isolated to the scrotum or may radiate to the lower abdomen. The pain is constant unless the testicle is torsing and detorsing. A typical presentation, particularly in children, is for the patient to awaken with scrotal pain in the middle of the night or in the morning. [1]

In a prospective study of 338 children with an acute scrotum evaluated at a single institution, the following clinical scoring system for testicular torsion was derived:

  • Nausea or vomiting: 1 point

  • Testicular swelling: 2 points

  • Hard testis on palpation: 2 points

  • High-riding testis: 1 point

  • Absent cremasteric reflex: 1 point

A score ≥5 diagnosed testicular torsion with a sensitivity of 76 percent, specificity of 100 percent, and a positive predictive value of 100 percent (prevalence 15 percent). A score ≤2 excluded testicular torsion with a sensitivity of 100 percent, a specificity of 82 percent, and a negative predictive value of 100 percent. A retrospective validation of this score in 116 children seen for acute scrotum at a different institution found similar results [2].

Bell clapper deformity [8]

2. Who is most likely to present with testicular torsion?

Testicular torsion has two peak incidences: a small one in the neonatal period and a large one during puberty, but it can occur at any age. The incidence is estimated to be 1 in 4000 in males younger than 25 years old [3]. Approximately 65 percent of cases occur in boys between the ages of 12 and 18 years [4]. The increased incidence during adolescence is thought to be secondary to the increasing weight of the testes during pubertal development. The most common abnormality associated with testicular torsion is known as the "bell clapper" deformity: The testicle lacks the normal attachment to the tunica vaginalis (permitting increased mobility) and rests transverse within the scrotum. The bell clapper deformity may be bilateral and predisposes to testicular torsion [5].

Manual detorsion of the testicle [8]

3. Should ED docs be performing manual manipulation to reduce testicular torsions?

Children and adolescents with testicular torsion based upon clinical findings or documented on ultrasound undergo an attempt at manual detorsion prior to surgery if emergency operative care is not rapidly available. An observational study of 133 patients (median age 16 years) with testicular torsion, successful manual detorsion (72 patients) was associated with a testicular salvage rate of 97 percent compared with 75 percent salvage in patients in whom detorsion was not attempted or was not successful [6]. After appropriate sedation and analgesia has been administered, manual detorsion is performed by grasping the testicle and rotating it within the scrotum outward (medial to lateral) one to two full 360 degree turns. Prompt relief of pain, lower position of the testis in the scrotum, and return of arterial flow on Doppler ultrasound suggests detorsion. If there is no improvement, try rotating the testicle in the opposite direction (lateral to medial) because approximately one-third of torsed testicles may have lateral rotation. The classic teaching is that the testis usually rotates medially and is detorsed by rotating it outward toward the thigh. However, in a retrospective analysis of 200 consecutive boys aged 18 months to 20 years who underwent surgical exploration for testicular torsion, lateral rotation was present in one-third of cases [7].

4. How does the amount of time from definitive treatment effect likely of testicle being salvageable?

  • Detorsion within 4 to 6 hours: 97 to 100 percent viability

  • Detorsion after 12 hours: 20 to 61 percent viability

  • Detorsion after 24 hours: 0 to 24 percent viability [8]

ALL patients with suspicion for testicular torsion should have immediate urologic consultation for potential operative exploration and repair while ultrasound is pending.

POST BY: DR. HALEY DURDELLA (PGY3)

FACULTY EDITING BY: DR. RILEY GROSSO

References

1. Tunnessen WW Jr. Scrotal swelling. In: Signs and Symptoms in Pediatrics, 3rd, Lippincott, Williams & Wilkins, Philadelphia 1999. p.606.

2. Barbosa JA, Tiseo BC, Barayan GA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013; 189:1859.

3. Williamson RC. Torsion of the testis and allied conditions. Br J Surg. 1976; 63:465.

4. Edelsberg JS, Surh YS. The acute scrotum. Emerg Med Clin North Am. 1988; 6:521.

5. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am. 1997; 44:1251.

6. Dias Filho AC, Oliveira Rodrigues R, Riccetto CL, Oliveira PG. Improving Organ Salvage in Testicular Torsion: Comparative Study of Patients Undergoing vs Not Undergoing Preoperative Manual Detorsion. J Urol. 2017; 197:811.

7. Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: Direction, degree, duration, and disinformation. J Urol. 2003; 169: 663–665.

8. Brenner JS, Aderonke O. Causes of scrotal pain in children and adolescents. In: UpToDate,  Middleman AB, Fleisher GR, Baskin LS (Ed). UpToDate; 2021. Accessed 30 Oct 2021. https://www.uptodate.com/contents/causes-of-scrotal-pain-in-children-and-adolescents

Quality, EBMLauren McCaffertyquality, torsion, testicular torsion, pediatrics